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Showing results for tags 'System safety'.
Found 520 results
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Content Article
Dirty Dozen and COVID-19 (webinar, May 2020)
Claire Cox posted an article in Coronavirus (COVID-19)
There are fears around maintaining personal safety whilst ensuring patient safety. Staff need to protect both themselves and their families at home. Equally, it is essential that staff feel supported in identifying risks and the potential for errors with a robust mechanism in place to reduce, eliminate or mitigate such risks. The Human Factors 'Dirty Dozen' is a concept developed by Gordon DuPont. He described elements that can act as precursors to accidents or incidents, or influence people to make mistakes. This webinar, from the Clinical Excellence Commission, looks at ways you can identify risks or 'hot spots' in your area of work and then discuss with your team at handover and huddles and plan strategies to reduce, eliminate or mitigate the risks -
Content ArticleIn this video Dr. Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, interviews Helen Hughes the Chief Executive of Patient Safety Learning, on how we can better share learning about reducing harm in healthcare. Helen shares the resources that are available through Patient Safety Learning and how those passionate about safety can get involved.
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Content Article
Designing a safe space for neonatal care
Claire Cox posted an article in Process improvement
As well as designing specific products, ergonomists and human factors specialists can help understand how the space within which we work can be best designed. This can help encourage effective communication in a workplace, as well as considering the comfort of all those present. The Chartered Institute for Ergonomics and Human Factors have come together with stakeholders involved in the care of neonates to design a space that is safe for newborn babies and staff that care for them. -
Content Article
Improving birthing pool design
Claire Cox posted an article in Maternity
Chartered Institute for Ergonomics and Human Factors has come together with industry and maternity units to redesign birthing pools to ensure they are safe and ergonomical for users. Read the attached case study. -
Content Article
On 30 March, in response to the UK Government asking for business to provide thousands of ventilators to help tackle the Covid-19 pandemic, Patient Safety Learning published a blog with recommendations to ensure that ventilators are ‘safe in use’ (this means making sure they are as intuitive and easy to use for frontline staff as possible, reducing the potential for error).[1] In that blog, we outlined how we had brought together human factors/ergonomics and clinical experts to discuss the design, development and use of the equipment. -
Content ArticleRecently, there has been a lot of interest in some ideas proposed by Prof. Erik Hollnagel and labeled as “Safety-II” and argued to be the basis for achieving system resilience. He contrasts Safety-II to what he describes as Safety-I, which he claims to be what engineers do now to prevent accidents. What he describes as Safety-I, however, has very little or no resemblance to what is done today or to what has been done in safety engineering for at least 70 years. In this paper, Prof. Nancy Leveson, Aeronautics and Astronautics Dept., MIT, describes the history of safety engineering, provides a description of safety engineering as actually practiced in different industries, shows the flaws and inaccuracies in Prof. Hollnagel’s arguments and the flaws in the Safety-II concept, and suggests that a systems approach (Safety-III) is a way forward for the future.
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Content ArticleI had been away from the hospital for a week and I was reluctant to go back in, fearful of what I would face, but I am amazed at how much has been achieved in 7 days.
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Content ArticleA powerful essay from Dr Joshua Lerner, an Emergency Room (ER) doctor who currently works at the Leominster campus of UMass Memorial Health Alliance-Clinton Hospital in the US...
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News Article
Trusts criticise ‘completely chaotic’ covid-19 supply response
Patient Safety Learning posted a news article in News
Several trust procurement leads have expressed frustration with the government’s response to covid-19, with HSJ being told of shortages of crucial personal protective equipment, unpredictable deliveries and a lack of clarity from the centre NHS Supply Chain, which procures common consumables and medical devices for trusts, has been “managing demand” for an increasing number of PPE and infection control products for since the end of February to ensure “continuity of supply”. Some products, like certain polymer aprons, are unavailable altogether because of the increased demand and disrupted supply caused by the covid-19 outbreak. One procurement lead told HSJ: “They aren’t supplying enough, they aren’t fulfilling orders. It’s completely chaotic.” Another said his trust had “just enough to manage for the time being.” Read full story (paywalled) Source: HSJ, 20 March 2020 -
Content ArticleJames Munro, Chief Executive of Care Opinion, argues that there is extraordinary, yet untapped value in patient feedback which is not being recognised in current policy and practice. His blog follows the launch of the National Institute of Healthcare Research's (NIHR) themed review on using patient feedback to improve care. Gathering feedback from people who use health services sounds like a simple and straightforward matter. Doesn’t everyone love feedback? The NIHR themed review Improving Care by Using Patient Feedback highlights that this is a topic beset by complexity, uncertainty and disagreement. It’s also an area which can provoke strong emotions both from those offering feedback, such as: “why isn’t anyone listening?” and those receiving it: “why am I being attacked when I work so hard?”.
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Content Article
WHO: What is patient safety?
Claire Cox posted an article in WHO
The World Health Organization has produced a factsheet about patient safety, what it is and the burden of harm. -
Content ArticleA&E is often seen as a service in crisis and is the focus of much media and political interest. But A&E is just the tip of the iceberg -- the whole urgent and emergency care system is complex, and surrounded by myth and confusion. This animation from The King's Fund gives a whistle-stop tour of how the system fits together and busts some myths about what's really going on -- explaining that the underlying causes go much deeper than just A&E and demand a joined-up response across all services.
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Content ArticleScienceDirect uses heuristic and machine-learning approaches to extract relevant information from their extensive collection of content. They compile this information on a topic-by-topic basis providing the reader both depth and breadth on a specific area of interest. This collection of research and data focuses on safety risk management.
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Content ArticleThis conceptual article published in The Joint Commission Journal on Quality and Patient Safety describes the barriers and facilitators of adopting, implementing, and sustaining the Patient and Family Advisory Councils on Quality and Safety (PFACQS) model across a large, geographically diffuse health system. Successful strategies that emerged include active board engagement, co-creation and mentorship by experienced patient advocates to support enhanced engagement by local PFACQS community members, and clear alignment with and line of sight on organisational quality and safety goals. It concludes that implementing a robust network of PFACQS focused on improving quality and patient safety requires leadership commitment to transparency, as well as mutual respect and trust. Establishing clear guidelines, structures, and processes supports early adoption. Openness to continuous improvement and adaptations are important to programme success and contribute to programme sustainability.
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Content ArticleHuman factors are of pivotal importance to both patient safety and doctors’ wellbeing, says Peter Brennan and Tista Chakravarty-Gannon in this BMJ Opinion article. In this article they highlight what the General Medical Council (GMC) and other organisations are doing to support doctors to deliver good care for their patients through educational and support programmes, including the GMC’s new Professional Behaviours and Patient Safety Programmes (PBPS) being piloted across the UK. These programmes are designed to help improve doctors’ skills and confidence in addressing unprofessional behaviours. These initiatives should reduce medical error, improve patient safety and professional welfare, as well as enhancing team working.
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Content ArticleThe primary purpose of this document from the Society of Petroleum Engineers (SPE) is to allow HSE professionals who provide answers to the pre-qualification questionnaires to quickly establish if their companies apply human factors / human performance as per the industry guidance. Secondly, this guidance may be used by anyone who wishes to quickly get an insight into the industry guidance, without reading dozens of reports. To access the report you will need to fill in a form from the SPE website.
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Content ArticleNHS Digital are proposing to make changes in how private healthcare data is collected and with whom it is shared. This will involve trialling the suitability of existing NHS systems for the collection of private healthcare data and bringing it into line with the standards, processes and systems used for NHS funded care. These proposed changes are based on feedback the Acute Data Alignment Programme (ADAPt) programme has already received from a wide range of stakeholders. Wider insight from private and NHS healthcare providers, clinicians, the public and other key stakeholders is now welcomed as part of this consultation to ensure that we address any significant issues and concerns which could prevent the successful implementation of these changes. We expect this survey will take no more than 20 minutes to complete but will vary depending on the level of detail in your response.
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News Article
NHS Doctors bullied to the brink
Clive Flashman posted a news article in News
The Doctors’ Association UK has compiled stories from 602 frontline doctors which expose a startling culture of bullying and overwork in the NHS. The stories include: a pregnant doctor who fainted after being forced to stand up for 15 hours straight and being denied water. The junior doctor was subsequently shouted at in front of colleagues and patients on regaining consciousness and told it was her choice to be pregnant and that ‘no allowances would be made’. a doctor who told us that a junior doctor hung themselves in a cupboard whilst on shift and was not found for 3 days as no-one had looked for them. His junior doctor colleagues were not allowed to talk about his suicide and it was all ‘hushed up’. a doctor who was denied a change of clothes into scrubs after having a miscarriage at work despite her trousers being soaked in blood. Full press release -
Content ArticleThis study, published in the British Medical Journal, found that current algorithm based smartphone apps cannot be relied on to detect all cases of melanoma or other skin cancers. Test performance is likely to be poorer than reported here when used in clinically relevant populations and by the intended users of the apps. The current regulatory process for awarding the CE (Conformit Europenne) marking for algorithm based apps does not provide adequate protection to the public.
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News Article
The NHS In England: Patient safety news roundup from Harvard Law
Clive Flashman posted a news article in News
There is always a lot happening with patient safety in the NHS (National Health Service) in England. Sadly, all too often patient safety crises events occur. The NHS is also no sloth when it comes to the production of patient safety policies, reports, and publications. These generally provide excellent information and are very well researched and produced. Unfortunately, some of these can be seen to falter at the NHS local hospital implementation stage and some reports get parked or forgotten. This is evident from the failure of the NHS to develop an ingrained patient safety culture over the years. Some patient safety progress has been made, but not enough when the history of NHS policy making in the area is analysed. Lessons going unlearnt from previous patient safety event crises is also an acute problem. Patient safety events seem to repeat themselves with the same attendant issues. Read full story Source: Harvard Law, 17 February 2020 -
Content ArticleSystems and software engineering contribute not only to advancing and improving the delivery of healthcare but also to doing it more safely than has been the case in the past.
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Content ArticleThe PRAISe project tests the hypothesis that, together, positive reporting and appreciative inquiry can be used as an intervention to facilitate behavioural change and improvement in the related areas of sepsis management and antimicrobial stewardship.
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Content ArticleExpanding on his previous commentary 'What does all this safety stuff have to do with me', Dan Cohen, Patient Safety Learning's Trustee and former Chief Medical Officer at DATIX, has written this article for the hub on personal responsibility in patient safe care.
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Content ArticleThis blog, written by Human Factors expert Stephen Rice and published by Forbes, looks at what healthcare can learn from the success of the aviation industry when it comes to safety.
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Content Article
Why malnutrition matters in care homes? (October 2019)
Claire Cox posted an article in Community care
In this short video, Professor Martin Green explains why good nutrition in care homes is essential. He explains that screening patients before they come to the care home is a 'must do' rather than a 'nice to have'. This video was made for the National Nutrition awareness week in 2019.
